Hyponatraemia associated with cardiac tamponade and chronic fluid excess.

We describe a complex case of hyponatraemia with two aetiologies. A 49-year-old man who drank 6 litres of dilute alcohol per day presented confused and oedematous with a serum sodium of 95 mmol/litre. Urine sodium was <10 mmol/litre and urine osmolality 440 mOsmol/kg. Chest x-ray demonstrated a globular heart. ECG showed saddle-shaped ST elevation. ECHO demonstrated a large pericardial effusion causing marked tamponade. Following pericardiocentesis there was a marked diuresis; serum sodium returned to normal after 2 weeks. A full recovery ensued. Cardiac tamponade is associated with antidiuresis via release of antidiuretic hormone (ADH). Tamponade is also associated with antinatriuresis. Antidiuresis and antinatriuresis usually balance in cardiac tamponade; excessive fluid intake may have caused an imbalance in this case.

A simple two-stage model predicts response time distributions.

The neural mechanisms underlying reaction times have previously been modelled in two distinct ways. When stimuli are hard to detect, response time tends to follow a random-walk model that integrates noisy sensory signals. But studies investigating the influence of higher-level factors such as prior probability and response urgency typically use highly detectable targets, and response times then usually correspond to a linear rise-to-threshold mechanism. Here we show that a model incorporating both types of element in series - a detector integrating noisy afferent signals, followed by a linear rise-to-threshold performing decision - successfully predicts not only mean response times but, much more stringently, the observed distribution of these times and the rate of decision errors over a wide range of stimulus detectability. By reconciling what previously may have seemed to be conflicting theories, we are now closer to having a complete description of reaction time and the decision processes that underlie it.

Venous excess: a new approach to cardiovascular control and its teaching.

The circulatory control system is driven partly by factors relating to the arterial side and partly by factors relating to the venous side. Students are generally provided with a conceptually clear account of the arterial side, based on sound homeostatic mechanisms of negative feedback from a well-defined error signal, arterial pressure. However, on the venous side, teaching is often based on the notion of venous return, a concept that, as normally presented, is imprecise and intangible, a frequent cause of confusion that may lead to errors of clinical practice. Although one can trace these misconceptions back to some of Guyton's publications, Guyton himself was well aware of the complexities of venous resistance and capacitance but has not always been well served by subsequent misinterpretation. The fundamental problem with venous return that makes it inappropriate for controlling the circulation is that it lacks the essential requirement of being an error signal. We propose instead a new variable, venous excess, which represents the accumulation of any mismatch between the rate of blood entering the great veins and the rate of leaving, the cardiac output. As well as being directly observable without intervention (in a patient's jugular vein), it meets all of the requirements of an error signal: via the Starling mechanism it stimulates cardiac output, regulates venous compliance, and in the longer term is an important determinant of fluid intake and excretion, and these effects act to reduce the original perturbation. Based on this concept, we suggest a simple and secure basis for teaching the control of the circulation that avoids undue reliance on entities that are difficult to specify or measure and emphasizes the role of feedback and the similarities between the arterial and venous mechanisms.

Accuracy, information, and response time in a saccadic decision task.

Reaction times generally follow a simple law economically described by the LATER model, in which a decision signal rises linearly in response to information about a target to a threshold at which a response is initiated, at a rate that varies from trial to trial with a Gaussian distribution. Functionally, LATER may be regarded as an ideal decision mechanism incorporating prior probability, information, and criterion level or urgency; this can be tested quantitatively by seeing whether LATER accurately predicts the effects on latency distributions of manipulating these variables: in this case, information and urgency. We presented subjects with random-dot kinematograms while fixating a central LED. The information content of the display was varied by altering the proportion of the dots moving coherently together either left or right rather than randomly. As soon as subjects detected the direction of coherent movement, they made a saccade in the same direction to one of a pair of LEDs on each side of the fixation target. Subjects responded either carefully, taking time to ensure an accurate judgement, or more hastily and with less regard for accuracy. The distributions of latencies under the different combinations of conditions were found to conform to LATER's predictions. Providing more information or increasing urgency both reduce latency; but they alter the observed distributions in different ways, equivalent to increasing the mean rate of rise on the one hand or reducing the criterion level on the other. Making only simple assumptions about the underlying mechanisms, the observed changes can be accounted for quantitatively.